December 7, 2016 Session Codes: D4 (9:30am-10:45am) & E4 (11:15am - 12:30pm) Centralizing Multi-Hospital Mortality Reviews IHI 28 th National Forum Mark P Jarrett, MD, MBA, MS SVP, Chief Quality Officer, Assoc Medical Director Carole Lysaght Moodhe, MD Physician Advisor, Patient Safety Program Karen Nelson, RN, MBA, CPHQ Vice President, Clinical Excellence & Quality Susanne Schultz, RN, MBA, CPHQ Asst Vice President 1
Objectives Describe the centralized mortality review process used at Northwell Health Discuss key findings of the primary and secondary reviews Explain how a centralized mortality review process can enhance patient safety, improve quality of care and support value based purchasing initiatives across a multi-hospital organization The Presenters Have Nothing To Disclose 2
Key Facts The first and largest integrated health system in NY State 21 hospitals Children s Hospital 2 Psychiatric Hospitals 4 Nursing/Sub-acute facilities Over 450 ambulatory locations 13,600 affiliated physicians 3,900 member physician medical group Broad geographic coverage 7 Counties - 108 million population Provides care to 4 million persons 27% inpatient share $95 billion revenue A rated Insurance Company Over 90,000 members 61,000 employees * Largest private employer in NYS Major academic and research center A continuously growing footprint Comprehensive and full continuum of care *Inclusive of affiliates, 58,000 Northwell Health employees 3
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INSTITUTE FOR CLINICAL EXCELLENCE STRATEGIC PLAN (2016 2018) Mission Northwell Health strives to improve the health and quality of life for the people and the communities it serves by providing world-class service and patient-centered care Vision The vision of the Institute for Clinical Excellence is to help transform the organization to become the most trusted name in health care Clinical Excellence Clinical Excellence is the result of systems designed to achieve predictable, optimal outcomes that consistently meet or exceed customer expectations Copyright 2016, Northwell Health All Rights Reserved 5
Guiding Principles Patients first, safety always The Six Aims of the Institute of Medicine Healthcare must be: 1) Safe 2) Effective 3) Patient Centered 4) Timely 5) Efficient 6) Equitable Teamwork and open, two-way communication promote a culture of patient safety High reliability and resilience are essential for optimal patient outcomes Individuals make mistakes Expect them and prepare for them Institute for Clinical Excellence & Quality 6
2016-2017 Key Quality Priorities To Eliminate All Preventable Harm LOWEST MORTALITY REDUCE MORTALITY Example: Acute MI, Heart Failure, Pneumonia, COPD, Sepsis, Mortality Review ZERO SAFEST HEALTHCARE HEALTHCARE-ACQUIRED CONDITIONS Example: CAUTI, CLABSI, C diff, MRSA, SSI BEST VALUE EVIDENCE-BASED PRACTICE Example: Reduced Readmissions, Stroke, Advanced Illness 7
2016 NORTHWELL HEALTH STRATEGIC PARTNERSHIPS & PRIORITIES 8
Lowest Preventable Mortality The Patient! 3M Grouper Change Hospice Beds Documentation Coding IHI Mortality Tool Sepsis project HAC s (CLABSI, CAUTI) System-wide Mortality Tool and Data Base Hospitalist Redesign 9
Mortality Surveillance Identify and Prioritize Actionable Initiatives Issues Identified: Mortalities reviewed at individual hospitals No consistent process No database available at any hospital No means to aggregate/analyze data across organization System Response: Patient Safety Program established incorporating Mortality Surveillance Centralized Structure Reliable and Valid Review Process Standardized Surveillance and Second Level Review Tools Internal System Database Created for Entry and Analysis IOM: To Err is Human 1999 10
13 Hospitals Centralized Standard Mortality Review 100% Retrospective Digital Autopsy MR Review 11
Our Journey - Centralized Mortality Review Process 2011 IHI Strategic Partnership Expertise Resources Tools 2012 Senior Leadership Established a Patient Safety Program Patient Safety Team Experienced, Registered Professional Nurses (RNs) Physician Advisor Medical Record Reviews using the IHI Global Trigger Tool (GTT) 12
Institute for Healthcare Improvement 2x2 Matrix The This IHI evidence-based, 2 x 2 Matrix is peer used reviewed to analyze tool patient is mortalities used to identify based potential on the assigned areas for level further of care investigation the time of such admission, as: intensive care unit (ICU) or Appropriate Non-ICU, use and of ICU whether beds patients are Adequate use of hospice, or other end-of-life resources in admitted solely for comfort care alignment with patient/family wishes Use of best practices in ICU Appropriate level of care assignments Box 1 & 2 Opportunities Advance Directives Alternatives to hospital for end of life care Clarity of ICU Admission Criteria Box 3 & 4 Opportunities Was perfect care rendered? If not, could the outcome of death have been prevented? Was there a failure to recognize, plan or communicate? 13
Our Journey - Centralized Mortality Review Process (con t) 2013 Expanded Program 12 acute care hospitals Created Initial Mortality Review Tool and Glossary Enhanced Mortality Review Tool by Intra-Professional Team (June) Demographics Hospitalization/Readmission/Admit Source Level of care Adverse Events/Infection/Procedural Complications Case Summary, including events leading to expiration Advance care planning/end of Life Care IHI 2x2 Matrix Post-mortem documentation Triggers for second level review Developed Web-based Database (KQMI) Tested & Revised Implemented Across the Organization (October) 14
First Level Mortality Review Process Flow 15
Second Level Mortality Review Process Flow 16
Triggers for Second Level Review Criteria: Adverse Event contributed or led to death Major complication New onset medical problem unrelated to disease process May meet regulatory reportable event criteria Restraint use within 24 hours of expiration (excludes soft wrist restraints/mittens) RN determines case needs further review Appropriateness of level of care Failure to communicate Failure to plan Failure to recognize Quality of care issue 17
Further Enhancing the Process Inter-rater Reliability Testing among RNs Percent Agreement 92%-100% Kappa Score 06-10 Developed Peer Review Process for RNs to standardize referrals Decreased Referrals from 20% to < 10% Appropriateness of second level referrals increased from 65% in 2015 to 85% in 2016 (Q3 YTD) Clarified the Glossary of Terms Modified First Level Mortality Review Tool Streamlined Medical Record Review Development of Standardized Reports with Hospital Access 18
Report Data (examples) First Level Review Second Level Review Total number of mortality reviews Number of referrals for second level (site)review Top ten primary diagnoses Patient age range Admit source 24 hour, 7 and 30 Day Readmissions Deaths within 24 hours of admission Results of the IHI 2x2 Matrix Deaths related to an adverse event Deaths related to surgical/procedural events Referral/timeliness of end of life care Triggers for second level review Planning Communication Recognition Documentation Level of Care Standard of Care Preventability 19
Further Enhancing the Process (con t) Physician Education Great variability in the methods used and the depth of analysis by physicians in the system hospitals To standardize the process, an ilearn Module was created Physicians performing Second Level Reviews complete module and short quiz prior to participating in the program 20
Further Enhancing the Process (con t) ilearn Module Course Objectives: Explain the significance of the IHI 2 x 2 Matrix Describe the components of the Medical Record used to conduct the Second Level Review Perform a comprehensive Deep Dive Second Level Mortality Review Answer Deep Dive questions pertaining to harm Identify pattern of harm such as: Failure to Communicate Failure to Plan Failure to Recognize 21
Further Enhancing the Process (con t) ilearn Module Takes the physician through a hospital admission detailing how to toggle back and forth between all the stored patient data The goal is a thorough exhaustive review of the entire hospitalization Mortality Review Process I Review initial First Level Nurse Clinical Summary II Review point of access to the Health System - Pre-op medical clearance - Anesthesiologist evaluation - ER admission (check triage sheet, medications, vital signs, lab data on admission) - Review the initial level of care ICU/floor III Review of the Progress Notes and Consultant Notes IV Toggle through the EHR for data not in the progress notes; ie, nurses notes, flowsheet, vital signs, lab data, medications V Complete the electronic based Second Level Review form 22
Further Enhancing the Process (con t) Evaluation of the Death: Was the death preventable? Was the standard of care met? What was the cause of death? Were there opportunities to improve care in: Communication Care planning Recognition Documentation Level of care 23
Keys to Ongoing Success Physician Engagement Modification of tools/processes based on ellicted feedback Sharing of reports/results Ongoing Communication Example: Quick Tips: Locating the ilearn for Second Level Physician Mortality Course 24
Key Findings 25
Key Findings/Results First Level Mortality Reviews 12,502 Reviews conducted from 2014 through Q3 2016 Top Primary Diagnoses: Sepsis Acute Respiratory Failure Pneumonia Non STEMI / Subendocardial Infarct Admission Source of Home (68%) Disproved hypothesis that majority were from skilled nursing facilities 26
Key Findings/Results First Level Mortality January 2014 September 2016 The results from analysis of the IHI 2 x 2 Matrix provided important information about the appropriateness of level of care and care planning Data Source: KQMI Mortality Database Run Date: November 17, 2016 27
Key Findings/Results Second Level Mortality Review Northwell Health 2015 3Q 2016 Results Opportunities for Improvement Cases with opportunities for improvement 2015 2016 (Q3 YTD) 53% 73% Major Themes: Planning: Clinical Judgment, Delays, Interventional/Therapeutic Complication Communication: Teamwork, Escalation Recognition: Condition /Severity of Illness Documentation: Completeness/Accuracy Level of Care: Level of Care/Appropriateness of Treatment Setting 2015 2016 (Q3 YTD) 42% 26% 23% 21% 16% 23% 15% 23% 4% 7% Planning Communication Recognition Documentation Level of Care Note: Multiple OFI Categories may be selected for each individual case Data Source: KQMI Mortality Database Run Date: November 17, 2016 28
From Centralized Mortality Reviews to VBP AMI & HF Mortality 29
VBP - AMI and HF Mortality Program Established VBP Steering Committee September 2014 Pilot Site Visits Completed February 2015 Process Tool Submission to KQMI July 2015 Preliminary Reports Generated November 2015 Redesign of Process Tool to Database Application January 2016 Expansion to all system hospitals June 2016 Pilot Sites Chosen December 2014 System PICG Presentation March 2015 All Site Visits Completed September 2015 Regional Meetings December 2015 Pilot of Database Application February 2016 First Quarter preliminary reports presented September 2016 30
2016 AMI & HF Mortality Review Process Flow 31
Opportunities For Improvement Q1-Q2 2016 Reporting Acute myocardial infraction (AMI) Standard medication therapy (compliance 93%) DTB time <90 minutes (compliance 99%) Documentation of contraindication/exclusion criteria (compliance 87%) Heart Failure (HF) Standard medication therapy (compliance 84%; main outlier Aldosterone Antagonist) Documentation of medication contraindications (compliance 78%) Readmission Follow-up appointment scheduling prior to discharge Comprehensive medication reconciliation upon discharge 32
Centralized Mortality Review Process Further increase understanding of health care delivery and preventable versus expected death Beneficial in developing effective and targeted strategies to reduce preventable harm and mortality Standardized across multiple hospitals of varying types Easily replicated by other health care organizations 33
Thank you 34